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Rolfing® Structural Integration Health Intake Form

This information is important to adjust techniques and avoid any contraindications.  Medical information is never shared without client’s consent.
Please indicate any medical conditions you have had or currently have and provide any relevant information. This form is used as a guideline for further discussion about your general health and well-being. 

• As a client of Structure and Dynamics, I personally accept and agree to pay my balance in full, as my responsibility, to Structure and Dynamics at the time of service
• I acknowledge that there is a 24-hour Cancellation Policy or 48 hours’ notice for Monday appointments. I understand that if I do not cancel 24 hours before my scheduled appointment, or do not show for my appointment, I accept the responsibility of being charged the full amount of the appointment If, for any reason, Structure and Dynamics cannot make it to my scheduled appointment, a complimentary session will be offered.
• I understand Structure and Dynamics provides nontraditional rolfing consultations, therapies, and procedures that may not be covered by any private insurance, Medicaid, nor Medicare. If I choose to submit my a medical bill from Structure and Dynamics to any insurance provider, I may accept any reimbursement from that insurer as a payment to myself directly but do not permit this insurer to set any fee for services provided by Structure and Dynamics.
• I understand that should I not pay for services rendered, I may be responsible for all collection, court, attorney, and legal fees. • I understand that I have the right to request that Structure and Dynamics restrict how protected health information about me is used or disclosed for treatment, payment, or health care operations. I understand that Structure and Dynamics is not required to agree to this restriction. Structure and Dynamics complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
I give my permission for Structure and Dynamics to provide treatment as determined medically necessary. I acknowledge that I will have been given the opportunity to discuss the nature and purpose of the treatment; alternate methods of treatment; and the risks, complications and consequences associated with the administration of rolfing. These risks include but are not limited to: bruising, temporary increase in pain, inflammation, numbness, weakness or paralysis, or spinal headache. I further acknowledge that any questions I have regarding the procedure have been answered to my satisfaction and that I have been further told that any additional questions I may have will be answered. I have read (or have had read to me) the above consent. I fully understand that there is no guarantee of successful treatment has been implied. I understand that I am entitled to a copy of this consent form upon request. My consent authorizes arbitration as a solution for any malpractice claims and waives all court involvement.

Please feel free to ask questions at any time during the process. Client communication is vital to the work.